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Catcher's Knee: Posterior Femoral Condyle Juvenile Osteochondritis

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Catcher's Knee: Posterior Femoral Condyle Juvenile Osteochondritis ORIGINAL ARTICLE Catcher’s Knee: Posterior Femoral Condyle Juvenile Osteochondritis Dissecans in Children and Adolescents Mark J. McElroy, MS,* Patrick M. Riley, MD,w Frances A. Tepolt, MD,w Adam Y. Nasreddine, MA,w and Mininder S. Kocher, MD, MPH*w (J Pediatr Orthop 2016;00:000–000) Background: Juvenile osteochondritis dissecans is an idiopathic condition involving subchondral bone and articular cartilage in skeletally immature patients in whom the growth plates are steochondritis dissecans (OCD) of the knee is a lo- open, potentially leading to lesion instability. Because of the Ocalized pathologic process in which an area of sub- differing forces experienced by baseball/softball catchers versus chondral bone undergoes metabolic changes or position players, the age at which lesions develop and the diminished blood supply, potentially involving separation characteristics of the lesions themselves may differ between these of the bone and overlying cartilage from surrounding 2 populations. The purpose of the study was to examine relative bony tissue.1 Despite the condition first being described age and characteristics of osteochondritis dissecans (OCD) knee over 100 years ago by Paget2 and Konig,3 its precise eti- lesions in catchers compared with position players. ology and natural history remain largely speculative and Methods: Using a text-based search tool that queries clinic notes controversial. Ischemia, repetitive trauma, abnormal os- and operative reports, computerized medical records from 1990 sification, genetics, and inflammation have all been to 2014 from the Sports Medicine Program of a tertiary care postulated as etiological factors.4–8 Recent increased Children’s Hospital were searched to find children and adoles- participation and specialization in youth sports and the cents who had OCD of the knee, played baseball/softball, had a rising rate of OCD in skeletally immature athletes may specified field position, and had magnetic resonance imaging of support the theory of overuse and repetitive micro- the knee. Ultimately, 98 knees (78 patients) were identified: 33 trauma,9,10 with OCD recently being reported as the knees (29 patients) in catchers and 65 knees (49 patients) in fourth most common overall injury in young athletes seen noncatchers. Data collected included position played (catcher/ at a large pediatric hospital.11,12 Incidence in the general noncatcher), demographics (age, unilateral/bilateral, and sex), population has been reported to be <30/100,000.13,14 lesion severity, and sagittal and coronal lesion location. OCD has been classified as juvenile OCD (jOCD) if Results: When compared with noncatchers, catchers presented the growth plates are open and adult OCD if the growth at a younger age (P = 0.035) but were similar with respect to plates are closed.15 OCD has further been classified based bilateral involvement (P=0.115), sex (P=0.457), and lesion on location and stability, with the lateral aspect of the severity (P=0.484). Lesions in catchers were more posterior on medial femoral condyle being the most common loca- the femoral condyle in the sagittal plane (P=0.004) but similar tion.6,16–18 Both nonoperative10,19 and operative20–25 in location in the coronal plane (P=0.210). treatments have been described. Nonoperative treatment is Conclusions: Catchers developed OCD at a younger age and in a usually recommended for stable jOCD lesions with intact more posterior location on the medial and lateral femoral con- articular cartilage and typically consists of activity re- dyles than noncatchers. These results may represent the effects striction. Operative treatment is usually recommended for of repetitive and persistent loading of the knees in the hyper- adult OCD lesions, unstable lesions, and stable lesions that flexed position required of catchers. Increased awareness of this have failed nonoperative treatment. Surgical treatment risk may lead to surveillance and prevention programs. options include drilling, fixation, and chondral resurfacing. Level of Evidence: Level III—case-control study. Attention has been paid to overuse upper extremity Key Words: OCD, osteochondritis dissecans, baseball, softball, injuries in youth baseball and softball players including catcher, microtrauma Little League Shoulder, Little League Elbow, internal impingement of the shoulder, OCD of the capitellum, medial epicondyle apophyseal injuries, and ulnar collat- eral ligament injuries. Early detection of injuries and the From the *Harvard Medical School; and wDepartment of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA. establishment of pitch count regulations can reduce the 26–28 None of the authors received any external financial support. number of these injuries. However, little attention The authors declare no conflicts of interest. has been paid to overuse injuries of the lower extremity in Reprints: Mininder S. Kocher, MD, MPH, Department of Orthopaedic these athletes. In particular, the repetitive and persistent Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: mininder.kocher@ knee hyperflexion required to play baseball/softball childrens.harvard.edu. catcher may influence the development and characteristics Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. of OCD lesions. J Pediatr Orthop Volume 00, Number 00, ’’ 2016 www.pedorthopaedics.com | 1 Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. McElroy et al J Pediatr Orthop Volume 00, Number 00, ’’ 2016 FIGURE 1. Cohort selection. MRI indicates magnetic resonance imaging; OCD, osteochondritis dissecans. The purpose of this study was to describe the age of METHODS presentation and characteristics of OCD lesions of the knee in youth baseball and softball players and to de- Patient Population termine if these parameters differed between catchers and Inclusion criteria for the study were: children and position players. adolescents 18 years old or younger, OCD of the knee, 2 | www.pedorthopaedics.com Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. J Pediatr Orthop Volume 00, Number 00, ’’ 2016 Catcher’s Knee OCD in Children and Adolescents TABLE 1. Hefti Staging Scale for Osteochondritis Dissecans TABLE 2. Patient Characteristics Grouped by Catcher and Stage Description Noncatcher Position Metric Catchers Noncatchers P I Small change of signal without clear margins of fragment II Osteochondral fragment with clear margins but without fluid No. Patients (involved knees) 29 (33) 49 (65) between fragment and underlying bone Age (average ± SD) (y) 12.7 ± 2.0 13.7 ± 2.3 0.035 III Fluid is visible partially between fragment and underlying bone Laterality 4 bilateral 16 bilateral 0.115 IV Fluid is completely surrounding the fragment, but the fragment is 25 unilateral 33 unilateral still in situ Sex 25 M 45 M 0.457 V Fragment is completely detached and displaced (loose body) 4F 4F F indicates female; M, male. played baseball and/or softball at the time he/she pre- teochondritis dissecans” OR “ICD9 732.9 Unspecified sented with OCD, the position the patient played was osteochondropathy”). specified in the medical record, and magnetic resonance The final cohort consisted of 98 knees in 78 patients. imaging (MRI) of the affected knee was available. There were 33 knees in 29 catchers and 65 knees in 49 A computerized search was performed of the med- noncatchers. Only 6 of the 29 catchers reported playing ical records of a large tertiary care Children’s Hospital other positions in addition to catcher. from 1990 to 2014 using a text-based tool that queries clinical notes and operative reports. A detailed review of the records returned by the search was then performed to confirm that each patient met the inclusion criteria. The Measurements/Definitions results of this search and filtering process are shown Demographics in Figure 1. The original query was performed with the Demographics of the catcher and noncatcher following broad search string to maximize patient iden- groups were compared, including age at MRI imaging of tification: (“baseball” OR “softball”) AND (“OCD” OR the lesion, whether the patient had unilateral versus bi- “jOCD” OR “osteochondritis” OR “ICD-9 732.7 Os- lateral lesions, and sex. Lesion Severity The severity of each lesion was determined using 2 methods. First, a pediatric orthopaedic sports medicine fellow read T2-weighted MRIs to evaluate fluid within the lesion and T1-weighted MRIs to evaluate breaks in the articular cartilage. Each lesion was then graded using the Hefti staging scale,6 which defines the 5 stages outlined in Table 1. Second, for patients who required surgical treatment, the stage determined using the MRI was con- firmed by narrative accounts of the lesion from the pe- diatric orthopaedic sports medicine attending surgeon’s operative report. When disagreement existed between the fellow’s MRI read and the attending surgeon’s report, a second attending was consulted to read the MRI. FIGURE 2. Cahill and Berg classification system used for lesion location stratification. Regions are defined as follows: coronal plane (A) region 1—medial portion of medial femoral condyle; region 2—lateral portion of medial femoral condyle; region 3—between walls of intercondylar tunnel; region 4—medial portion of lateral femoral condyle; region 5—lateral portion of lateral femoral condyle; patella. Sagittal plane (B) region A— anterior
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